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Wednesday, June 26, 2013

1500-1900: Hospital staff will probably not cure your asthma

If you had asthma prior to the 20th century chances are you would not want to go to a hospital. These institutions were usually reserved for people who were desperate, miserable, and severely ill, such as those inflicted with the plague.

Surely there were hospitals built during the course of the 15th, 16th, 17th and 18th centuries with the intent on helping the sick, disabled, and wounded. Many of these institutions were established around military bases, although many others were established in or around cities.

Along with the many hospitals that were built in Europe, there were also some built in America. For instance, in 1524 Cortez set up a hospital in Mexico. Later hospitals were set up in Quebec, Canada, in 1639 and 1693, Montreal, Canada, in 1644, and on Manhattan Island in 1663. (1, page 308)

While hospitals were created with noble intentions, the results were often not so noble. For instance, surgeons at these hospitals performed surgeries, and more often than not the surgeon knew little more about anatomy and diseases than the person being operated on. Few lived to tell about how they survived an operation. The most common cause of death would be blood born pathogens, although this bit of knowledge would not be discovered until the mid 19th century (during the scientific revolution, or at the dawn of modern medicine).

Many of the hospitals had only a few patients, except during times of plagues and epidemics, which were frequently scattered throughout most of these centuries. As the size of cities grew, as populations rose, and especially when and where sewage and garbage exposed, so too rose ideal environments for vermin, bugs, and the diseases they carried. Chances are that every person either knew someone who suffered from or died of disease, or they survived one themselves.

I'm certain there were good stories told of successful operations, and recoveries as the result of care at such an institution, although many gloomy pictures are painted. For instance, one of the greatest medical historians of all time, Fielding Hudson Garrison, provides us with the following account:

Many new hospitals were built (in Europe) in the eighteenth century, but, in respect of cleanliness and administration, these institutions sank to the lowest level known in the history of medicine... (for example) In 1788, Jacobus-Rene Tenon published a series of memoirs on the hospitals of Paris, containing his famous description of the old Hotel Dieu, which was at that time a veritable hotbed of disease. There were some 1220 beds, the most of which contained from four to six patients, and about 486 beds for single patients. The larger halls contained over 800 patients crowded on pallets, or often lying about miserably on heaps of straw, which was in vile condition. Acute contagious diseases were often in close relation to mild cases, vermin and filth abounded, and the ventilation was often so abominable that the attendants and inspectors would not enter in the morning without a sponge dipped in vinegar held to their faces. Septic fevers and other contagia were the rule; the average mortality was about 20 per cent., and recovery from surgical operations was, in the nature of things, a rarity. (1, pages 416-417) (2, page 768-770)

Garrison quotes fellow historian John Herman Baas as saying:

"Even physicians declined hospital service as equivalent to a sentence to death." (1, page 416)

So how about the full quote by Baas. In his 1889 book, "Outlines of the history of medicine and the medical profession," Baas likewise describes the situation inside most hospitals as deplorable. He wrote:

Most of the hospitals were still in a lamentable, indeed, a dreadful condition, rather nests of disease than institutions for the cure of the sick: for hospital hygiene, with which even Theophrastus von Hohenheim (Paracelsus) was acquainted, was utterly lost sight of or neglected... Such was the condition of affairs almost everywhere, and it was not until the introduction of clinical instruction that the situation was somewhat improved... How horrible the sanitary conditions of the hospitals were at the close of the 18th and the beginning of the present century, may be judged from the fact that in some places, e. g. Frankfort-on-the-Main, even physicians declined hospital service as equivalent to sentence of death. (6, page 768-770)

Anatomical knowledge did start to improve during the course of the 18th century, so over time the ability to perform surgeries must have likewise improved. However, there continued to be a high death rate anytime a patient was cut open mainly due to the high rate of infections. There must have been a rise in successful surgeries, only to have the patient die later of infection.

Along with the exceptional men who inspired improvements anatomical wisdom, pathology, internal medicine, etc., there were also exceptional men (and women) who inspired humanitarian movements that resulted in improved hospital safety. Among the first such humanitarians was Florence Nightingale (1820-1910). She worked hard during the course of her life to improve unsanitary conditions at British hospitals, thereby reducing death rates by as much as two-thirds (2)

Surgeries continued to be performed rarely, and only in emergent situations, until the middle of the 19th century when the scientific revolution was in full swing. It wasn't until men like Oliver Wendell Holmes, Ignaz Philipp Semmelweis, Louis Pasteur, and Joseph Lister discovered that diseases were spread to patients by infected and unclean environments, and the means of preventing their spread was by creating a germ free environment.

So it was efforts by folks like these that, slowly, resulted in improved conditions at hospitals. Walls were painted white, and surgeons and nurses wore white linens so that dirt could easily be spotted. Physicians and nurses were likewise encouraged, if not ordered, to wash between patient visits, and after surgeries.

Yes, the profession of medicine was slow to adapt to change, although in time it did what was humane; it did what was right; it did what was scientifically proven to benefit of the general public. The result was a significant reduction in the spread of disease at hospitals, and a corresponding reduction in mortality.

Although while physicians were available at such institutions, and the remedies were probably on hand (what few and insignificant ones there were), these were not ideal places for asthmatics. Until the turn of the 20th century, and the invention of medicines like cortisol and epinephrine, asthmatics found better results by toughing it out, or calling for their family physician.

So none of the above had an immediate impact on asthma per se. However, with the advent of the germ theory of disease, this created a pathway to allow for a significant reduction, and in many cases eradication, of many diseases that plagued the civilized world. With those diseases controlled, scientists now had an opportunity to focus on that were widespread, although not so deadly -- such as asthma and allergies.

References:

Garrison, Fielding Hudson, "An introduction to the history of medicine," 1921, London and Philadelphia,